Chiro Consult Form

Personal Information

    How did you hear about us?

    Last Name
    First Name
    GenderMaleFemale
    Address
    City, Province
    Postal Code
    Phone (Home)
    Phone (Work)
    Phone (Cell)


    Alberta Health Care #
    Third Party Insurance #


    Emergency Contact Name
    Emergency Contact Phone


    Date of Birth
    Age
    Height
    Weight


    Occupation
    Marital Status
    SingleMarriedWidowedDivorced


    Email address
    Email will be used for [ACAC member to customize, e.g., appointment reminders, receipts,
    birthday emails, etc.]


    Please check all answers and fill in the blanks where appropriate

    Reason(s) for appointment:

    When did your condition begin?

    Have you ever had similar problems? YesNo

    Have you had X-rays, MRI, or other tests for this condition?
    YesNo
    Which tests, when?


    Is this a work related injury?
    YesNo
    Has your employer been notified?
    YesNo


    Is this a Motor Vehicle Accident (MVA)?
    YesNo
    On what date did the accident occur?



    Can you perform daily home activities? YesYes, but only with helpNot at all

    Can you perform your daily work activities? All activitiesOnly some activitiesNot at all

    Describe your stress level NoneMildModerateHigh


    Do you exercise? DailyOccasionallyNot at all

    What kinds of exercise do you do?

    List all previous surgeries, illnesses, injuries (including MVA):

    Have you had previous chiropractic care? YesNo
    Dr
    Date



    List all medications, over the counter and prescriptions, supplements, vitamins, herbal supports, aspirin, etc.:

    Health History Questionnaire

    Have you ever been diagnosed or told you have any of the following?
    High blood pressure YesNo

    Hardening of the arteries (arteriosclerosis) YesNo

    Diabetes YesNo

    Tuberculosis YesNo

    Cancer
    YesNo
    Where?



    Heart or blood diseases YesNo

    Bone spurs on the neck bones (cervical sprain) YesNo

    Whiplash injury (flexion-extension injury, cervical sprain) YesNo

    Have you or any of your relatives ever suffered a stroke? YesNo

    Were you ever a smoker? YesNo

    Do you take medication on a regular basis? YesNo clear="all">
    Visual disturbances (blurring, loss, double vision) YesNo

    Hearing disturbances (loss, ringing, other noise) YesNo

    Slurred speech or other speech problems YesNo

    Difficulty swallowing YesNo

    Dizziness YesNo

    Loss of consciousness, even momentary blackouts YesNo clear="all">
    Numbness, loss of sensation, loss of strength or weakness in the face, fingers, hands, arms, legs, or any other
    parts of the body?     YesNo

    Sudden collapse without loss of consciousness YesNo

    AUTHORIZATION FOR TREATMENT

    I understand the nature of the treatment provided by Dr. Jess Fong, and agree to work with him to attain my optimum health. I will provide as much background information as necessary and I realize that this information is confidential and is strictly used for the benefit of my treatment. I understand the fee policy of treatments I will receive. Fees are due when services are rendered and I am responsible for payment. A fee will be charged for appointments missed or cancelled without 24 hours notice.


    Waiver (Please read carefully and sign)

    I attest that the information I have provided is true and complete to the best of my knowledge.

    • I consent to treatments by account all practitioners at Euphoria Wellness Centre
    • I understand that I am responsible for any charges incurred in the course of my treatment.
    • I understand 24 hours notice is required to reschedule all appointments, or charges will apply.
    • I understand that No refunds are available on gift cards or massage packages. Packages cannot be combined or exchanged with other offers. Gift cards and packages are non-transferable.
    • I release the practitioner from any and all liability from problems arising from the treatment as a result of information given or not given, or incorrectly given in this history form. Because my personal and medical information is confidential, I understand that none of this information will be shared unless I give my consent in writing.
    • For my own safety and for the safety of the public: Intoxication (alcohol use or otherwise) will not be tolerated. Practitioners and/or Management have the right to refuse service should any signs of intoxication be present (eg. odour, slurred speech, belligerence, etc.) before or during my treatment. The full cost of the treatment will be charged to my account.
    • I, (print name) hereby fully understand the acupuncture treatment process and the possible effects such as:
      • fainting
      • small bruises
      • post-acupuncture sensation (numbness, tingling, heaviness, and tiredness
      • temporary exacerbation of symptoms

    I agree to fully disclose all past and current health conditions. I shall give consent to have acupuncture
    treatment.


    Client Signature:
    Date:


    Parent/Guardian Signature (if client under 18 years of age)